I am a chiropractor by profession but I do not offer chiropractic adjustments or any form of manual therapy in my practice. How did I do it? Does it work?

To give some context, we started as a multimodal practice. This means we do everything. From chiropractic adjustment to IASTM to dry needling to exercise therapy, we did it all. Six months ago, we decided to drop everything but exercise. Why? Because the latest research said it was better. Since the transition, we are starting to see clients leaving our care earlier with fewer follow ups. Today, over 80% of our clients are discharged from our care within four to seven visits pain-free and with full function. How do we achieve this? Education.

And believing in that there is a genuine group of people who are willing to do what it takes to break out of their pain cycle. Is this you?

Understanding pain science

We are big on education at Square One. Education is essential to what we do and we can’t emphasise on it enough. We try our best to explain to our clients why their pain hurts, how pain is not a good indicator of injury or damage. In essence, it’s okay to feel pain and it doesn’t mean there is something wrong.

When it comes to pain, we still largely fall back to the alarm system analogy. If a burglar breaks into a car, the alarm will go off. If the alarm system is too sensitive, all it would take is for a cat to jump on it to set it off. In this instance, has the car been broken into? No.

Likewise, pain works to warn our body of threats or potential threats. It’s possible for it to malfunction. For most people with chronic pain, it is more likely a case of an out-of-sync alarm than an actual injury. No, this does not mean your pain is not real. In fact, it is very real.

It is also fixable.

Read more about pain mechanisms and how chronic pain works: All You Need to Know about Pain: Elite Athlete Edition.

Education + exercise is a better combination

Believe it or not, education + exercise is a better combination than manual therapy + exercise. We have data to support this. In a study just published last week, Fersum et al. found that cognitive functional therapy is better than manual therapy + exercise at reducing disability, depression/anxiety and pain related fear at three-year follow up. When it comes to pain intensity, there was no difference between both groups at the end of three years (i.e. there were comparable improvements in both groups).

This means that participants who received education + exercise (no manual therapy) had more capacity to live their daily life than those who received manual therapy + exercise.

In short, you don’t need manual therapy. In fact, the no-manual therapy group fared better than the group that received manual therapy.

What is cognitive behavioural therapy?

Our model of care at Square One closely mirrors cognitive behavioural therapy (CFT). CFT is a individualised self-management approach to treating chronic low back pain. It is developed based on the biopsychosocial approach to pain and focuses on teaching people about their pain and helping people gain confidence to perform normal movement or activities relating to their goals.

There are three main components in CFT. They are:

  1. Making sense of pain
  2. Exposure with “control”
  3. Lifestyle change

Before we move on, it’s a good idea to read the following two articles to learn more about pain:

1. Making sense of pain

To help you make sense of your pain, you will be guided through an interview process. During this interview, you will discuss your pain experience and the therapist will explain the (multidimensional) factors that may contribute to your pain. Beliefs that are considered unhelpful are dispelled. During this interview, mutually-agreed goals are also set for the appropriate behaviour change.

We think this is the most important part of recovery. During this stage, both you and the clinician are synced to be on the same page. We share with you the truths of pain and injury while you tell us what is important to you as well as your goals and expectations. This means we will be able to work together to get you to where you want to be without wasting your time and money on what doesn’t matter.

2. Exposure with “control”

The second stage is where the fun begins. In this stage, you will be exposed to functional movement exercises. Strategies will also be developed to help you to normalise posture and movements relevant to your lifestyle. E.g. movements that aggravate symptoms or were feared by the participant). These functional movement exercises are then integrated into activities that may provoke or aggravate the symptoms in your day to day life (i.e. running).

For us, these movements are either broken down into smaller parts or combined into more complex movements for you to do at home. We believe in the cumulative effects of exercise and the results really do speak for themselves!

It is not uncommon for clients to experience some discomfort or even pain at this stage. But don’t worry. Remember, pain is not an indication or damage or injury. We will guide you through this process and provide all the help you may need.

3. Lifestyle change

I guess the last stage is fairly straight forward. In this stage, you will be encouraged to pick up various health habits such as regular physical activity, good sleep hygiene, good stress management.

It sounds good, no? Cognitive functional therapy is a truly holistic way to look at pain. To reiterate, it doesn’t include any form of manual therapy (chiropractic adjustments, dry needling, soft tissue therapy, etc).

Less visits, more results

As we mentioned earlier cognitive functional therapy gives you better results. But how often do you need to come see me? Majority of our clients (more than 80% of them) see us for between four to seven visits across a three month period. We think that is super reasonable and unfortunately the caveat is that you have to be compliant to the exercises we prescribed.

In this study, the participants saw a therapist for seven to eight individualised sessions over 12 weeks and still enjoyed lesser disability, pain-related fear, and pain intensity after three years!

(Just to clarify, participants in the CFT group did see their pain scores decreasing but not superiorly to the manual therapy + exercise group.)

You do not need chiropractic adjustments

We are super proud to be the first exercise-based chiropractor in Singapore. We also stubbornly maintain that you do not need manual therapy to get better. While other chiropractors may sell chiropractic adjustments to you as a need, we do not think that is true.

We have showed you the numbers, have they?

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